Document 17006
County Medical Services Program (CMSP) Forms Effective December 1, 2004 Reduced Eligibility Certification (REC) Policy Changes Status as of November 12, 2004 Number Title Rev. Date 1A Change to Limited Length of Eligibility Dec. 2004 (Conversion NOA) 1A (FPL) Info Notice 1 Info Notice 2 210 Dec. 2004 Dec. 2004 Dec. 2004 Dec. 2004 219 237 239 A 239 B Dec. 2004 Dec. 2004 Dec. 2004 Dec. 2004 239 F-A Dec. 2004 239 F-D Dec. 2004 239 P 1153 Dec. 2004 Sep. 2004 NA 9 Dec. 2004 NOA Back Dec. 2004 Eligibility Brochure Dec. 2004 Provider Information Brochure Change to Limited Length of Eligibility (Conversion NOA) Important Inforamtion About the CMSP Summary CMSP Eligibility Application for CMSP Usage notes One time only usage for converting cases to certification limits and income test policy effective 12/04 One time only usage for converting cases to certification limits and income test policy effective 12/04 Rights, Responsibilities & Other Info Caseload Movement & Activity Report Denial/Discontinuance of Benefits Approval/Denial of Benefits Approval of Companion Benefits to Long Term Care Discontinuance of Companion Benefits to Long Term Care Approval/Denial of Benefits Restricted to Emergency Medical Services CMSP Medical Linkage Evaluation Forms Unchanged by REC Policy: 239 E 239 R 239 U 239 V 609 610 611 1054 1175 1176 1178 1179 1180 Mar. 1999 Overpayment and Repayment Inst. Discontinuance Notice - Deceased Aug. 2003 Persons Aug. 2003 Utilization of Property Aug. 2002 Utilization of Business Property Aug. 2002 Co. Request for CMSP Claims Detail Dec. 2003 Claims Transmittal/Case Resolution Dec. 2003 CMSP Overpayment Check Handling Jul. 2002 SOC Provider Letter Aug. 2003 Medical Care Hearing Request Apr. 1999 Potential Third Party Liability Notification Jul. 2002 Profit and Loss Statement Dec. 2003 Eligibility Expenditure Report by FY Request for CMSP Data and Other Feb. 2004 Inforamtion/Assistance Forms Discontinued/Obsoleted by REC Effective 12/1/04: 176 SQ 177 P 239 C 239 G Aug. 2003 Sep. 2003 Jul. 2002 Aug. 2003 239 I Jul. 2002 239 Q Jul. 2002 Quarterly Status Report Record of Healthcare Cost Spenddown Change in SOC Spenddown of Property Discon of Benefits Status Report Not Received or Not Completed Change From Restricted Svcs to Full Benefits Language Status Eng/Sp English and Spanish sent in ACL 04-12 Eng/Sp Eng only Eng only Eng/Sp English and Spanish sent in ACL 04-12 English sent in ACL 04-12 Sent in ACL 04-12 Sent in ACLs 04-09 and 04-11 Eng/Sp Eng only Eng/Sp Eng/Sp English and Spanish sent in ACL 04-12 Sent in ACL 04-12 English and Spanish sent in ACL 04-12 English sent in ACL 04-12 new form Eng/Sp Currently under development by CMSP staff new form Eng/Sp Currently under development by CMSP staff Eng/Sp Eng/Sp English sent in ACL 04-12 Sent in ACL 04-09 Eng/Sp Eng/Sp Eng only Counties generate their own form. Changes underway by CMSP staff Changes underway by CMSP staff new CMSP application revisions include elimination to Hunt v Kizer policy yes language specific to individual county yes yes State of California – Health and Human Services Agency Department of Health Services COUNTY MEDICAL SERVICES PROGRAM NOTICE OF ACTION ┌ ┐ └ ┘ CHANGE TO LIMITED LENGTH OF ELIGIBILITY Case name:___________________ Case number: _________________ District: _______________________ This affects: ___________________ (Name) This notification is to inform you of changes to your County Medical Services Program (CMSP) eligibility. Effective January 1, 2005, CMSP rules have changed. The number of months you can get CMSP is limited and your income cannot exceed 200% of the Federal Poverty Level. Your benefits have been converted to these new rules. Your current eligibility period will end the last day of _________________. (month/year) Your share of cost for this period is: $___________per month. You will be automatically discontinued from CMSP at the end of the month stated above. If you continue to need aid after the date of discontinuance, you can reapply beginning in your last month of eligibility. Please do not reapply sooner. Do not throw your plastic ID card away. You can use it again if you become eligible for CMSP or Medi-Cal. The authority that requires this action is in CMSP All County Letter No. 04-07 and/or appropriate CMSP Eligibility Manual sections. _________________________________ Eligibility Worker ______________ Phone PLEASE READ THE REVERSE SIDE OF THIS NOTICE CMSP 1A (12/04) ___________ Date ESTADO DE CALIFORNIA - AGENCIA DE SALUD Y SERVICIOS HUMANOS CALIFORNIA DEPARTAMENTO DE SERVICIOS DE SALUD PROGRAMMA DE SERVICIOS MEDICOS DEL CONDADO (CMSP) NOTIFICACIÓN DE ACCIÓN Cambio al Tiempo Limitado de Elegibilidad ┌ ┐ └ ┘ Nombre del Caso: Numero del Caso: Districto: Esto Afecta: ___________________ ___________________ ___________________ ___________________ (Nombre) Esta notificación es para informarle de los cambios a su elegibilidad del Programa de Servicios Médicos del Condado (CMSP). Comenzando el 1 de enero de 2005, las reglas de CMSP han cambiado. El número de los meses que alguien se permite permanecer en CMSP es limitado y sus ingresos no pueden exceder la cantidad permitida debajo del Programa de 200 por ciento del Nivel de Pobreza Federal. Sus beneficios se han convertido a estas reglas nuevas. Su elegibilidad actual se terminará el último día de _________________. (mes/ año) Su parte del costo por este períódo es: $_________________________ por mes. Automáticamente usted sera descontinuado del CMSP al fin del mes indicado arriba. Si usted continúa necesitando la ayuda después de la fecha de la discontinuación, usted puede aplicar de nuevo empezando en el último mes de su elegibilidad. Por favor no reaplique antes del último mes. No tire su tarjeta de identificación de CMSP. Usted puede utilizarla otra vez si usted es elegible de nuevo para CMSP o Medi-Cal. La autoridad que requiere esta acción esta en la carta “CMSP All County Letter No. 04-07” o en las secciónes apropiadas del Manual de la Elegibilidad de CMSP. _________________________________ Nombre del/de Trabajador(a) de Elegibilidad ____________________ Telefono Por favor lea el reverso de este aviso. CMSP 1A SP (12/04) ____________________ Fecha State of California – Health and Human Services Agency Department of Health Services COUNTY MEDICAL SERVICES PROGRAM NOTICE OF ACTION ┌ ┐ └ ┘ CHANGE TO LIMITED LENGTH OF ELIGIBILITY Case name:___________________ Case number: _________________ District: _______________________ This affects: ___________________ (Name) This notification is to inform you of changes to your County Medical Services Program (CMSP) eligibility. Effective January 1, 2005, CMSP rules have changed. The number of months you can get CMSP is limited and your income cannot exceed 200% of the Federal Poverty Level. Your benefits have been converted to these new rules. Your current eligibility period will end the last day of _________________. (month/year) Your income exceeds 200% of the Federal Poverty Level. You will be automatically discontinued from CMSP at the end of the month stated above. If you continue to need aid after the date of discontinuance, you can reapply beginning in your last month of eligibility. Please do not reapply sooner. Do not throw your plastic ID card away. You can use it again if you become eligible for CMSP or Medi-Cal. The authority that requires this action is in CMSP All County Letter No. 04-07 and/or appropriate CMSP Eligibility Manual sections. _________________________________ Eligibility Worker ______________ Phone PLEASE READ THE REVERSE SIDE OF THIS NOTICE CMSP 1A (FPL) (12/04) ___________ Date ESTADO DE CALIFORNIA - AGENCIA DE SALUD Y SERVICIOS HUMANOS CALIFORNIA DEPARTAMENTO DE SERVICIOS DE SALUD PROGRAMMA DE SERVICIOS MEDICOS DEL CONDADO (CMSP) NOTIFICACIÓN DE ACCIÓN Cambio al Tiempo Limitado de Elegibilidad └ Nombre del Caso: Número del Caso: Districto: Esto Afecta: ┘ ___________________ ___________________ ___________________ ___________________ (Nombres) Esta notificación es para informarle de los cambios a su elegibilidad del Programa de Servicios Médicos del Condado (CMSP). Comenzando el 1 de enero de 2005, las reglas de CMSP han cambiado. El número de los meses que alguien se permite permanecer en CMSP es limitado y sus ingresos no pueden exceder la cantidad permitida debajo del Programa de 200 por ciento del Nivel de Pobreza Federal. Sus beneficios se han convertido a estas reglas nuevas. Su elegibilidad actual se terminará el último día de _________________. (mes/año) Sus ingresos exceden la cantidad permitida debajo del Programa de 200 por ciento del Nivel de Pobreza Federal. Automáticamente usted sera descontinuado del CMSP al fin del mes indicado arriba. Si usted continúa necesitando la ayuda después de la fecha de la discontinuación, usted puede aplicar de nuevo empezando en el último mes de su elegibilidad. Por favor no reaplique antes del último mes. No tire su tarjeta de identificación de CMSP. Usted puede utilizarla otra vez si usted es elegible de nuevo para CMSP o Medi-Cal. La autoridad que requiere esta acción esta en la carta “CMSP All County Letter No. 04-07” o en las secciónes apropiadas del Manual de la Elegibilidad de CMSP. _________________________________ Nombre del/de Trabajador(a) de Elegibilidad ____________________ Telefono Por favor lea el reverso de este aviso. CMSP 1A (FPL) SP (12/04) ____________________ Fecha State of California—Health and Human Services Agency Department of Health Services County Medical Services Program IMPORTANT INFORMATION ABOUT THE COUNTY MEDICAL SERVICES PROGRAM (CMSP) PLEASE UNDERSTAND THAT CMSP IS NOT THE MEDI-CAL PROGRAM. When eligible for CMSP, you will receive a plastic State of California Benefits Identification Card (BIC) and a MedImpact (MI) card. Please see the backside of this notice for instructions on when to use these cards. The length of time you will be eligible to receive CMSP benefits is limited. You will be notified of this limited certification period. MISUSE OF YOUR BIC OR MI CARDS COULD RESULT IN A REDUCTION OF YOUR BENEFITS, TERMINATION OF YOUR ELIGIBILITY, AND/OR PROSECUTION (TITLE 22, CCR, SECTION 50733(d)). BENEFITS. You should always carry your cards with you. Your cards may be used only by you to receive the following care: Acute inpatient hospital care (including acute inpatient rehabilitation) Adult day health care services Medical supplies, when prescribed by a licensed practitioner within the scope of his/her practice, or durable medical equipment dealers, and prosthetic and orthotic providers Audiology services Nonemergency medical transportation Blood and blood derivatives Occupational therapy services Optometry services (see excluded benefits below) Chronic hemodialysis services Outpatient clinic services Dental services Outpatient heroin detoxification services Durable medical equipment Pharmaceutical services provided by network pharmacists (ask your county department for a list of network pharmacies) Emergency air and ground ambulance services Hearing aids Physical therapy services Physicians’ services Home health agency services Hospital outpatient services Laboratory and radiology services Podiatry services Prosthetic and orthotic appliances Rehabilitation clinics Speech therapy services EXCLUDED BENEFITS. CMSP does not include the following services: Eye appliances including frames, lenses, contact lenses, low-vision aids, and prosthetic eyes. Pregnancy-related services (contact your county eligibility office) Long-term care facility services (contact your county eligibility office) Services of chiropractors, acupuncturists, psychologists, licensed clinical social workers, or marriage and family therapists If you need or desire medical care which is not covered by CMSP, you must pay for it yourself or make other arrangements with the provider. Check with your county health department for possible health care resources available in your county. See the backside of this notice for additional important information. CMSP INFORMATION NOTICE 01 (12/04) ENFORCEMENT OF CMSP AS A SECONDARY PAYER. CMSP is the “provider of last resort.” If you are infected with HIV or AIDS, are seeking family planning services, or have Hepatitis C, you may be eligible for services through other state programs. The other state programs are: 1. California AIDS Drug Assistance Program (ADAP)—for information, call (916) 445-0553. 2. Family Planning, Access, Care, and Treatment Program (Family PACT)—for information, call (800) 942-1054. 3. Hepatitis C—Drug Company Patient Assistance Programs (PAPs)—information is available on the internet at: www.helpingpatients.org. Your medical provider may also be able to provide information. You must use these programs before receiving services from CMSP. If you need prescriptions, your physician or pharmacy will need to provide documentation that you were not able to obtain services from the above mentioned programs. Without this proof, medications related to medical conditions covered by the above programs will be denied. Information on the prior approval process can be found at www.cmspcounties.org. USING YOUR CARD. You should always carry your BIC and MI cards with you. Your providers will use the plastic BIC card to identify you and process your share-of-cost (SOC), if any. Additionally, your pharmacy will use the MI card to bill CMSP for prescriptions. In an emergency, obtain medical care immediately, even if you do not have your cards with you. Remember, however, to tell the provider that you are covered by CMSP and show the provider your card(s) as soon as possible after you have received care. PRIOR AUTHORIZATIONS. There may be some limitations on the amount of care you may receive with your cards. Also, many services may require prior approval by CMSP consultants before they are given. Your doctor or other provider should know the limitations, and is responsible to request any necessary approval from the California Department of Health Services. (Note: Local Medi-Cal field offices approve treatment requests for CMSP medical services, dental service requests are processed by Denti-Cal, and pharmacy service requests are processed by MI.) COPAYMENTS. You may be required to pay $1 for medication prescriptions, $1 for office visits, and $5 for emergency room visits which are not emergencies. SHARE-OF-COST. Some persons eligible for CMSP have a SOC obligation. If you have a SOC, you must pay, or agree to pay, part of your monthly income toward your medical expenses before CMSP will pay for covered benefits. Your county worker will explain how this works. CERTIFICATION PERIODS. Depending on what CMSP eligibility category you are in, your time on CMSP (certification period) will be different. Clients who are eligible for emergency services only will be certified for two months. Clients with a SOC will be certified for three months and clients without a SOC will be certified for six months. If you have a need to continue services beyond your certification period, you will need to apply for benefits again. FINDING A PROVIDER. Remember: the person or facility providing care does not have to accept the BIC or MI cards. Find out if the provider accepts the card before you go for treatment or services. It is your responsibility to show the provider your cards at the time you receive services. CMSP payments to your provider are considered payment in full for the services which you receive, although these payments may be less than a provider’s usual and customary charges. Aside from your possible SOC, you are not obligated to pay any difference between the provider’s charges and CMSP’s rate of payment. BILLING THE PROGRAM. Only Medi-Cal or MI providers of services are eligible to bill CMSP. If your provider does not accept CMSP and you decide to pay for the services in order to continue seeing that provider, CMSP cannot reimburse you for those services. OTHER HEALTH COVERAGE. You are required to notify your county eligibility office if you are covered by any health insurance carrier. Other health coverage (OHC) information will be identified on your CMSP eligibility record, and providers of service must bill the OHC prior to billing CMSP. THIRD PARTY LIABILITY. You are required to report to your county eligibility office when CMSP will be billed for health care services you received as a result of an accident or injury caused by some other person’s action or failure to act. FAIR HEARING. If you are dissatisfied with any decisions regarding medical care under the CMSP, you have the right to request a hearing by the Department of Social Services. You should either request a copy of the Medical Care Hearing Request, form CMSP 1175, from your eligibility worker or telephone the Public Inquiry and Response Unit at 1-800-952-5253. The completed form CMSP 1175 should be mailed to the address listed on the form. CMSP INFORMATION NOTICE 01 (12/04) State of California—Health and Human Services Agency Department of Health Services County Medical Services Program SUMMARY CMSP ELIGIBILITY Description of Eligible Person Medically indigent adult who meets all CMSP eligibility criteria and is not eligible for Medi-Cal. Age Limits 21 through 64 years of age. Residence and Citizenship California residence. Residence in a CMSP county. Full Benefits: A citizen of the United States or an alien who is: lawfully admitted for permanent residence; permanently residing in the United States under color of law. Emergency Services Only: Persons whose immigration status has not been determined. Personal Property Limits Number of Persons Whose Property is Considered Property Limit 1 person .............................................................................. $2,000 2 persons ............................................................................ 3,000 3 persons ............................................................................ 3,150 4 persons ............................................................................ 3,300 5 persons ............................................................................ 3,450 6 persons ............................................................................ 3,600 7 persons ............................................................................ 3,750 8 persons ............................................................................ 3,900 9 persons ............................................................................ 4,050 10 or more persons............................................................. 4,200 Spenddown of excess property permitted. Motor Vehicle Limits One vehicle exempt—no maximum value. Real Property Limits Principal residence, including any appertaining buildings and land used as a home is exempt if the applicant/beneficiary lives there. Other real property with a net market value of $6,000 or less is exempt if utilization requirements are met. Income Limits Less than or equal to 200% of the Federal Poverty Level (based on the net nonexempt income). Relative Responsibility Spouse for spouse. Parent for ineligible child living in parent’s home. CMSP Monthly Maintenance Need Need Standard 1 person .............................................................................. $ 600 2 persons ............................................................................. 750 2 adults ................................................................................ 934 3 persons ............................................................................. 934 4 persons ............................................................................. 1,100 5 persons ............................................................................. 1,259 6 persons ............................................................................. 1,417 7 persons ............................................................................. 1,550 8 persons ............................................................................. 1,692 9 persons ............................................................................. 1,825 10 or more persons.............................................................. 1,959 Each additional person, add $14. Share-of-Cost (SOC) Net nonexempt income minus maintenance need equals share-of-cost. Share-of-cost must be paid or obligated before certification for program benefits. Certification Period Limits 2 months—emergency services only 3 months—share-of-cost 6 months—no share-of-cost Clients wishing to continue their eligibility beyond the certification period may reapply. Provider Network All approved Medi-Cal and MedImpact providers—not limited to providers in CMSP counties. Please note that this is a general summary. For exceptions and details, consult your county welfare department. CMSP Information Notice 2 (12/04) State of California—Health and Human Services Agency Department of Health Services County Medical Services Program (CMSP) COUNTY MEDICAL SERVICES PROGRAM (CMSP) RIGHTS, RESPONSIBILITIES, AND OTHER INFORMATION Print name of applicant Date Print name of person acting for applicant Relationship to applicant Be sure you have read every item, and sign and date. Read the following carefully before signing. ● ● I understand that I am applying for the County Medical Services Program and that I am not applying for the state Medi-Cal Program. I understand that I have declared citizenship or immigration status on the CMSP 210, MC 13, MC 210, SAWS 2, or other Medi-Cal form. I understand that my declaration of citizenship or immigration status for Medi-Cal eligibility will also be used in determining CMSP eligibility. CMSP RIGHTS, RESPONSIBILITIES, AND OTHER INFORMATION You have the right to: ● Ask for an interpreter to help you in applying for CMSP benefits if you have difficulty in speaking or understanding the English language. ● Be treated fairly and equally regardless of your race, color, religion, national origin, sex, age, or political beliefs. ● Apply for CMSP benefits and to be told in writing whether or not you qualify for CMSP, even if the county representative tells you during the interview that it appears that you are, or are not now, eligible. ● Review manuals containing the rules of the CMSP if you want to question the basis on which your eligibility is approved or denied. ● Receive a Benefits Identification Card (BIC) as soon as possible if you have a medical emergency. ● Have all information you give to the county department kept in the strictest confidence. ● Qualify for the CMSP by reducing your property reserve to within the CMSP property limit by the last day of any month, including the month of application. ● Receive an explanation of possible ways that you may spend your excess property as long as you receive adequate consideration. ● Speak to a social service worker about other public or private services or resources that may be available to you. ● Request a hearing from the county if you are dissatisfied with an action taken, or not taken, by the county Department of Social Services. If you wish such a hearing, you must request one within 30 days of the date the Notice of Action was mailed to you. If you do not receive a Notice of Action, you must request the hearing within 30 days of the date that you became aware of the action of which you are dissatisfied. You have the responsibility to: ● ● ● ● ● ● ● ● ● ● ● ● Present when requested verification that you are a resident of the county in which you are applying for CMSP. Tell your medical provider (doctor, dentist, etc.) that you have applied for CMSP or are a CMSP beneficiary. Sign and keep your BIC and use it only to obtain necessary health care. Take your BIC to your medical provider when you receive medical care, as soon as possible if you receive services and do not have your BIC with you. Provide a social security number to the county or apply for one. Apply for Medicare benefits if you are blind, disabled, or aged 64 years and 9 months or older and are eligible for these benefits. Apply for any income which may be available to you or your family members. Report to the county department any health care insurance that you have or are entitled to have. Use any health insurance which you have before using the CMSP. Report to the county department when CMSP benefits received are a result of an accident or injury caused by some other person’s action or failure to act. Cooperate with the county if your case is selected for a quality control review. Cooperate with Medi-Cal regulations if you are potentially eligible for Medi-Cal (this includes the disability evaluation process). If you do not cooperate and you are found ineligible for Medi-Cal, you will not be eligible for CMSP benefits. YOU HAVE THE RESPONSIBILITY TO NOTIFY YOUR COUNTY ELIGIBILITY WORKER WITHIN TEN DAYS WHENEVER: ● ● ● ● You move or plan to move to another address in your county, to another county, or to another state or country. You plan to be away from your home (residence) for more than 60 days. Any person moves into or out of your home. You or your spouse enters or leaves a nursing home or long-term care facility. CMSP 219 (12/04) Page 1 of 2 ● ● ● You or a family member becomes pregnant or the pregnancy ends. You or a family member applies for any disability benefits, such as SSI/SSP, Social Security, Railroad Retirement, Veterans Benefits, Workers’ Compensation, etc. You or a family member has a change in health insurance, citizenship, or immigration status. I UNDERSTAND THAT: ● ● ● ● ● ● ● ● ● When I apply for CMSP benefits I will be evaluated for eligibility for other programs including Medi-Cal. If I obtain medical services from a medical provider who is not a CMSP provider, I will be responsible for the cost of the services I receive. Based on my income, I may have to pay, or be billed for, some of my own medical expenses each month before the CMSP will begin to pay. If I give false or incomplete information, I may be found ineligible for the CMSP and I may be investigated for suspected fraud. The facts I give may be checked by computer with information from employers, the Franchise Tax Board, Social Security Administration, banks, welfare, and other agencies. If I, or a person I am applying for, do not have documentation of satisfactory immigration status, I, or the person I am applying for, may be eligible only for emergency CMSP services. If I do not report changes promptly, and I receive CMSP benefits that I am not eligible for, I may have to repay the CMSP for those benefits. If I am eligible for other health insurance at no cost to me and do not apply for it or fail to keep such insurance, my CMSP eligibility may be denied or discontinued. If my medical provider accepts my CMSP for covered services, they cannot bill me for those services except for any share-of-cost that I may have. I realize that if I deliberately make false statements or withhold information, I (or the person on whose behalf I am acting) may lose my CMSP eligibility and/or I can be prosecuted for fraud. I hereby state that I have read the information on this form and that I fully understand my RIGHTS AND RESPONSIBILITIES to have my eligibility determined for the CMSP and to maintain that eligibility. I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE ANSWERS I HAVE GIVEN ARE CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE. Signature of applicant Phone number ( Signature of person acting for applicant Relationship to applicant ( I have provided to the applicant (check one) information listed on this form. in person EW number (if applicable) by mail Date ) Phone number ( Signature of Eligibility Worker (EW) (if applicable) ) Phone number Signature of witness (If applicant signed with mark) Date Date ) the rights, responsibilities, and other Phone number ( Date ) Privacy and Confidentiality Notification Sections 14011 and 14012 of the Welfare and Institutions Code authorize county social service/welfare departments to collect certain information from you to determine if you or the person(s) you are applying for are eligible for CMSP benefits. The information you provide is confidential and may only be disclosed to certain individuals or organizations and then only to administer the CMSP. This information will be used by the county department to establish initial and ongoing CMSP eligibility; by the State’s fiscal intermediary for claims processing purposes; by the California Department of Health Services for BIC production, health insurance identifications, and overpayment recovery actions; for Medicare Buy-In and social security number verification; by the Immigration and Naturalization Service to determine alien status; and by medical providers of services and health maintenance organizations for eligibility verification. Providing this information is mandatory. Failure to do so will result in your ineligibility for CMSP benefits. You have the right to look at your information and may do so at the county department during regularly scheduled office hours. CMSP 219 (12/04) Page 2 of 2 State of California—Health and Human Services Agency Department of Health Services County Medical Services Program (CMSP) DERECHOS, RESPONSABILIDADES Y OTRA INFORMACIÓN DEL PROGRAMA DE SERVICIOS MÉDICOS DEL CONDADO (CMSP) Escriba el nombre del/de la solicitante en letra de molde Fecha Escriba el nombre de la persona que actúa en nombre del/de la solicitante en letra de molde Parentesco con el/la solicitante Asegúrese de haber leído cada cosa, y firme y ponga la fecha. Lea lo siguiente detenidamente, antes de firmar. O Entiendo que estoy solicitando beneficios del Programa de Servicios Médicos del Condado (County Medical Services Program—CMSP), y que no estoy solicitando beneficios del Programa de Medi-Cal del estado. O Entiendo que he declarado mi ciudadania o mi situación migratoria en las formas CMSP 210, MC 13, MC 210, SAWS 2, o otra forma del Medi-Cal. Entiendo que mi declaración de ciudadania o situación migratoria para la eligibilidad de Medi-Cal también sera utilizada en la determinación de elegibilidad para el CMSP. DERECHOS, RESPONSABILIDADES Y OTRA INFORMACIÓN SOBRE EL CMSP Usted tiene derecho a: O Pedir que un(a) intérprete le ayude a solicitar los beneficios del CMSP, si usted tiene dificultades para hablar o entender el idioma inglés. O Que se le trate justa y equitativamente independientemente de su raza, color, religión, origen nacional, sexo, edad o creencias políticas. O Solicitar beneficios del CMSP, y a que se le informe, por escrito, si usted reúne los requisitos o no para el CMSP, aun si el/la representante del condado le informa a usted durante la entrevista que parece ser que si reúne los requisitos o que no los reúne ahora. O Revisar los manuales que contengan las reglas del CMSP, si usted desea cuestionar el fundamento bajo el cual se aprobó o negó su elegibilidad. O Recibir una Tarjeta de Identificación de Beneficios (Benefits Identification Card—BIC) lo antes posible, si tiene una emergencia médica. O Que toda la información que usted proporcione al departamento del condado se mantenga en la confidencialidad más estricta. O Reunir los requisitos para el CMSP, al reducir su reserva de bienes para que esté dentro del limite de bienes del CMSP, a más tardar el último día de cualquier mes, incluyendo el mes de su solicitud. O Recibir una explicación sobre las posibles maneras en que usted puede gastar su exceso de bienes, siempre y cuando usted reciba consideración adecuada. O Hablar con un(a) trabajador(a) de servicios sociales sobre otros servicios o recursos públicos o privados que podrían estar a su disposición. O Solicitar una audiencia del condado, si usted está insatisfecho(a) con una acción que el Departamento de Servicios Sociales del condado haya tomado o no. Si usted desea una audiencia tal, tiene que solicitarla en un plazo de 30 días, a partir de la fecha en que se le envió la Notificación de Acción. Si usted no recibe una Notificación de Acción, usted tiene que solicitar la audiencia en un plazo de 30 días, a partir de la fecha en que usted se dio cuenta de la acción con la que usted está insatisfecho(a). Usted tiene la responsabilidad de: Presentar, cuando se le pida, comprobante de que usted es residente del condado en el que esté solicitando beneficios del CMSP. O Informarle a su proveedor médico [doctor(a), dentista, etc.] que usted ha solicitado beneficios del CMSP, o que es beneficiario(a) del CMSP. O Firmar y guardar su BIC, y usarla solamente para obtener atención médica necesaria. O Llevar su BIC a su proveedor médico cuando usted reciba atención médica, lo antes posible, si usted recibe servicios y no tiene su BIC consigo. O Proporcionar un número de seguro social al condado, o solicitar uno. O Solicitar beneficios de Medicare, si usted está ciego(a), incapacitado(a) o tiene 64 años y 9 meses de edad o más, y reúne los requisitos para estos beneficios. O Solicitar para cualquier ingreso que podría estar a su disposición o a la de sus familiares. O Reportar al departamento del condado cualquier seguro de atención médica que usted tenga o al que tenga derecho. O Usar cualquier seguro médico que usted tenga, antes de usar el CMSP. ● Reportar al departamento del condado cuando los beneficios del CMSP recibidos son el resultado de un accidente o lesión causado por la acción de alguna otra persona, o por que no actuó. O Cooperar con el condado, si su caso se selecciona para una evaluación de control de calidad. O Cooperar con los ordenamientos de Medi-Cal, si posiblemente usted reúna los requisitos para recibir Medi-Cal (esto incluye el proceso de evaluación de incapacidad). Si usted no coopera, y se determina que no reúne los requisitos para recibir Medi-Cal, usted no reunirá los requisitos para recibir beneficios del CMSP. O CMSP 219 (SP) (12/04) USTED TIENE LA RESPONSABILIDAD DE NOTIFICAR A SU TRABAJADOR(A) DE ELEGIBILIDAD DEL CONDADO, EN UN PLAZO DE DIEZ DÍAS, CUANDO: O Usted se mude o planea mudarse a otra dirección en su condado, a otro condado o a otro estado o país. O Usted planea ausentarse de su hogar (residencia) durante más de 60 días. O Alguna persona se mude a o fuera de su hogar. O Usted o su cónyuge ingrese o salga de un centro de convalecencia o establecimiento de atención a largo plazo. O Usted o una pariente resulte embarazada o el embarazo se termine. O Usted o un(a) pariente solicite algún beneficio por incapacidad, como SSI/SSP, seguro social, Jubilación de Ferrocarriles, Beneficios para Veteranos, Compensación para los Trabajadores, etc. O Usted o un(a) pariente tenga un cambio en seguro médico, ciudadanía o situación migratoria. ENTIENDO QUE: ● Cuando solicite beneficios del CMSP, se me hará una evaluación para determinar mi elegibilidad para otros programas, incluyendo Medi-Cal. O Si obtengo servicios médicos de un proveedor médico que no sea un proveedor del CMSP, seré responsable del costo de los servicios que reciba. O En base a mis ingresos, es posible que tenga que pagar, o que se me cobren, algunos de mis propios gastos médicos cada mes, antes de que el CMSP comience a pagar. O Si doy información falsa o incompleta, es posible que se determine que no reúno los requisitos para el CMSP, y que se me investigue por sospecha de fraude. O Los datos que se corroborarán por computadora con información de empleadores, el Departamento de Impuestos del Estado, la Administración del Seguro Social, bancos, departamentos de asistencia pública y otras agencias. O Si yo, o una persona para la que estoy solicitando beneficios, no tenemos documentación o una situación migratoria satisfactoria, yo, o la persona para la que estoy solicitando beneficios, posiblemente reunamos los requisitos solamente para servicios de emergencia del CMSP. O Si no reporto cambios oportunamente, y recibo beneficios del CMSP para los que no reúno los requisitos, es posible que tenga que pagarle al CMSP tales beneficios. O Si reúno los requisitos para otro seguro médico, sin costo alguno para mí, y no lo solicito, o no retengo dicho seguro, mi elegibilidad del CMSP posiblemente se me niegue o descontinúe. O Si mi proveedor médico acepta mi CMSP para los servicios cubiertos, no pueden cobrárme tales servicios, excepto cualquier parte del costo que pudiera tener. Estoy consciente de que si hago declaraciones falsas o retengo información deliberadamente, yo (o la persona en cuyo nombre estoy actuando) podríamos perder la elegibilidad del CMSP, o prodriamos ser procedados por fraude. Por este medio, declaro que he leído la información en este formulario, y que entiendo plenamente mis DERECHOS Y RESPONSABILIDADES, para que se determine mi elegibilidad para el CMSP, y para mantener esa elegibilidad. DECLARO, BAJO PENA DE PERJURIO, CONFORME A LAS LEYES DEL ESTADO DE CALIFORNIA, QUE LAS RESPUESTAS QUE HE DADO SON CORRECTAS Y VERDADERAS A MI LEAL SABER Y ENTENDER. Firma del/de la solicitante Número de teléfono ( Firma de la persona que actúa en nombre del/de la solicitante Relación con el/la solicitante Firma del/de la testigo (si el/la solicitante firmó con una huella) ) Número de teléfono ( por correo Fecha ) Número de teléfono ( Fecha Fecha ) Le he proporcionado al solicitante (marke uno) otra información enumerada en esta forma. en persona los derechos, las responsabilidades, y la Firma del/de la Trabajador(a) de Elegibilidad (EW) (si es pertinente) Número del/de la EW (si es pertinente) Número de teléfono ( Fecha ) Notificación de Privacidad y Confidencialidad Las Secciones 14011 y 14012 del Código de Instituciones y Asistencia Pública autoriza a los departamentos de servicios sociales y de asistencia pública del condado a que recopile cierta información de usted, para determinar si usted o la(s) persona(s) para la(s) que esté solicitando beneficios reúne(n) los requisitos para beneficios del CMSP. La información que usted proporcione es confidencial, y solamente puede revelárseles a ciertos individuos o organizaciones, y entonces solamente para administrar el CMSP. Esta información la utilizará el departamento del condado para establecer la elegibilidad inicial y continua del CMSP; el intermediario fiscal del Estado para fines de tramitar reclamos; el Departamento de Servicios de Salud para la producción de BICs, identificaciones de seguro médico y medidas para recuperar pagos excesivos e indebidos; para comprobar números de seguro social y números otorgados por Medicare; el Servicio de Inmigración y Naturalización para determinar la situación como extranjeros; y los proveedores de servicios médicos y organizaciones para la conservación de la salud para comprobar la elegibilidad. El proporcionar esta información es obligatorio. El no hacerlo resultará en su inelegibilidad para beneficios del CMSP. Usted tiene derecho a ver su información, y puede hacerlo en el departamento del condado durante horas hábiles regulares. CMSP 219 (SP) (12/04) State of California—Health and Human Services Agency Department of Health Services INDIVIDUAL MOVEMENT AND ACTIVITY REPORT (County Medical Services Program Only) Mail or fax one copy to: California Department of Health Services Office of County Health Services MS 5202 1501 Capitol Avenue, Suite 5195 P.O. Box 997413 Sacramento, CA 95899-7413 County Report month Fax number: (916) 552-8018 Intake Activity Denied (Income) Approvals 1. Pending applications on hand at beginning of month........................ 2. New applications ............................................................................... 3. Reapplications (3a + 3b + 3c + 3d) ................................................... a. Reapplication without break ......................................................... b. Reapplication within two months.................................................. c. Reapplication within three months ............................................... d. Reapplication with more than 3 months and less than 1 year ..... Denied (Property) Denied (Other) Withdrawals Pending 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 4. Total applications on hand during the month (1 + 2 + 3)......................................................................................................................................... 5. Total applications disposed during the month (5a + 5b + 5c).................................................................................................................................. a. Approvals .................................................................................... 52 .............................................................................................. b. Denials (5bi + 5bii + 5biii)................................................................................................................................................................................... i. Total 1 Over income .............................................................................................. 50 51 53 54 55 ii. Over property................................................................................................................. 56 iii. Other.................................................................................................................................................. 57 c. Withdrawals................................................................................................................................................................. 58 6. Pending applications carried forward to next month ........................................................................................................................... 59 7. Annual redetermination of eligibility for 8F-only clients ........................................................................................................................................... 8. Total disposed and redetermination activity (5 + 7)................................................................................................................................................. 60 61 62 Continuing Activity 9. Continuing individuals on hand at beginning of month............................................................................................................................................ 10. Individuals added during month (10a + 10b) ........................................................................................................................................................... a. Individuals added from intake (5a) .................................................................. b. Other approvals............................................................................................... 66 12. Total individuals discontinued during month ........................................................................................................................................................... a. End of certification period................................................................................................................................................................................... b. Linked to Medi-Cal ............................................................................................................................................................................................. SSI ............................................................................................................. ii. DAPD......................................................................................................... iii. Other.......................................................................................................... 68 69 70 72 73 d. Client requested—other ..................................................................................................................................................................................... e. Other .................................................................................................................................................................................................................. 13. Continuing individuals carried forward to next month (11–12) ................................................................................................................................ CMSP 237 (6/04) 67 71 c. Client requested—wanted to reapply with budget change................................................................................................................................. County person to contact regarding this report 64 65 11. Total continuing individuals during month (9 + 10).................................................................................................................................................. i. 63 Telephone number Date prepared 74 75 76 77 County Medical Services Program Form 237 Cell-by-Cell Description - Final Cell Number Description Cell 1 This cell represents the total number of CMSP applications that were pending at the beginning of the report month and were approved in the report month. Cell 2 This cell represents the total number of CMSP applications that were pending at the beginning of the report month and were denied in the reporting month due to excess income. Cell 3 This cell represents the total number of CMSP applications that were pending at the beginning of the report month and were denied in the report month due to excess resources. Cell 4 This cell represents the total number of CMSP applications that were pending at the beginning of the report month and were denied in the report month due to other reasons. Cell 5 This cell represents the total number of CMSP applications that were pending at the beginning of the report month and were withdrawn in the report month. Cell 6 This cell represents the total number of CMSP applications that were pending at the beginning of the report month and were still pending at the end of the report month. Cell 7 This Cell represents the arithmetic total of Cell 1, Cell 2 ,Cell 3, Cell 4, Cell 5 and Cell 6. Cell 8 This cell represents the total number of new CMSP applications that were received during the report month and were approved during the report month. Cell 9 This cell represents the total number of new CMSP applications that were received during the report month and were denied during the report month due to excess income. Cell 10 This cell represents the total number of new CMSP applications that were received during the report month and were denied during the report month due to excess resources. Cell 11 This cell represents the total number of new CMSP applications that were received during the report month and were denied during the report month due to other reasons. Cell 12 This cell represents the total number of new CMSP applications that were received during the report month and were withdrawn during the report month. Cell 13 This cell represents the total number of new CMSP applications that were received during the report month and were still pending at the end of report month. Cell 14 This Cell represents the arithmetic total of Cell 8, Cell 9,Cell 10, Cell 11, Cell 12 and Cell 13. Cell 15 This Cell represents the arithmetic total of Cell 22, Cell 29,Cell 36 and Cell 43. Cell 16 This Cell represents the arithmetic total of Cell 23, Cell 30,Cell 37 and Cell 44 Cell 17 This Cell represents the arithmetic total of Cell 24, Cell 31,Cell 38 and Cell 45 Cell 18 This Cell represents the arithmetic total of Cell 25, Cell 32,Cell 39 and Cell 46 Cell 19 This Cell represents the arithmetic total of Cell 26, Cell 33,Cell 40 and Cell 47 Cell 20 This Cell represents the arithmetic total of Cell 27, Cell 34,Cell 41 and Cell 48 Cell 21 This Cell represents the arithmetic total of Cell 28, Cell 35,Cell 42 and Cell 49 Cell 22 This cell represents the total number of CMSP re-applications taken without break that were received during the report month and were approved during the report month. Cell 23 This cell represents the total number of CMSP re-applications taken without break that were received during the report month and were denied during the report month due to excess income. Cell 24 This cell represents the total number of CMSP re-applications taken without break that were received during the report month and were denied during the 237 final Cell by Cell v1.3 County Medical Services Program Form 237 Cell-by-Cell Description - Final Cell 25 Cell 26 Cell 27 Cell 28 Cell 29 Cell 30 Cell 31 Cell 32 Cell 33 Cell 34 Cell 35 Cell 36 Cell 37 Cell 38 Cell 39 Cell 40 Cell 41 Cell 42 Cell 43 report month due to excess resources. This cell represents the total number of CMSP re-applications taken without break that were received during the report month and were denied during the report month due to other reasons. This cell represents the total number of CMSP re-applications taken without break that were received during the report month and were withdrawn during the report month. This cell represents the total number of CMSP re-applications taken without break that were received during the report month and were still pending at the end of the report month. This Cell represents the arithmetic total of Cell 22, Cell 23, Cell 24, Cell 25, Cell 26 & Cell 27. This cell represents the total number of CMSP re-applications taken with a 2 month break that were received during the report month and were approved during the report month. This cell represents the total number of CMSP re-applications taken with a 2 month break that were received during the report month and were denied during the report month due to excess income. This cell represents the total number of CMSP re-applications taken with a 2 month break that were received during the report month and were denied during the report month due to excess resources. This cell represents the total number of CMSP re-applications taken with a 2 month break that were received during the report month and were denied during the report month due to other reasons. This cell represents the total number of CMSP re-applications taken with a 2 month break that were received during the report month and were withdrawn during the report month. This cell represents the total number of CMSP re-applications taken with a 2 month break that were received during the report month and were still pending at the end of the report month. This Cell represents the arithmetic total of Cell 29, Cell 30, Cell 31, Cell 32, Cell 33 & Cell 34. This cell represents the total number of CMSP re-applications taken with a 3 month break that were received during the report month and were approved during the report month. This cell represents the total number of CMSP re-applications taken with a 3 month break that were received during the report month and were denied during the report month due to excess income. This cell represents the total number of CMSP re-applications taken with a 3 month break that were received during the report month and were denied during the report month due to excess resources. This cell represents the total number of CMSP re-applications taken with a 3 month break that were received during the report month and were denied during the report month due to other reasons. This cell represents the total number of CMSP re-applications taken with a 3 month break that were received during the report month and were withdrawn during the report month. This cell represents the total number of CMSP re-applications taken with a 3 month break that were received during the report month and were still pending at the end of the report month. This Cell represents the arithmetic total of Cell 36, Cell 37, Cell 38, Cell 39 , Cell 40 & Cell 41. This cell represents the total number of CMSP re-applications taken with more than a 3 month break (but less than 1 year) that were received during the report 237 final Cell by Cell v1.3 County Medical Services Program Form 237 Cell-by-Cell Description - Final Cell 44 Cell 45 Cell 46 Cell 47 Cell 48 Cell 49 Cell 50 Cell 51 Cell 52 Cell 53 Cell 54 Cell 55 Cell 56 Cell 57 Cell 58 Cell 59 Cell 60 Cell 61 Cell 62 Cell 63 Cell 64 Cell 65 Cell 66 Cell 67 Cell 68 Cell 69 Cell 70 Cell 71 Cell 72 Cell 73 month and were approved during the report month. This cell represents the total number of CMSP re-applications taken with more than a 3 month break (but less than 1 year) that were received during the report month and were denied during the report month due to excess income. This cell represents the total number of CMSP re-applications taken with more than a 3 month break (but less than 1 year) that were received during the report month and were denied during the report month due to excess resources. This cell represents the total number of CMSP re-applications taken with more than a 3 month break (but less than 1 year) that were received during the report month and were denied during the report month due to other reasons. This cell represents the total number of CMSP re-applications taken with more than a 3 month break (but less than 1 year) that were received during the report month and were withdrawn during the report month. This cell represents the total number of CMSP re-applications taken with more than a 3 month break (but less than 1 year) that were received during the report month and were still pending at the end of the report month. This Cell represents the arithmetic total of Cell 43, Cell 44, Cell 45, Cell 46 , Cell 47 & Cell 48. This Cell represents the arithmetic total of Cell 7, Cell 14, Cell 21 This Cell represents the arithmetic total of Cell 53 , Cell 54 & Cell 58 This Cell represents the arithmetic total of Cell 1, Cell 8, Cell 15 This Cell represents the arithmetic total of Cell 52 This Cell represents the arithmetic total of Cell 55, Cell 56, Cell 57 This Cell represents the arithmetic total of Cell 2, Cell 9, Cell 16 This Cell represents the arithmetic total of Cell 3, Cell 10, Cell 17 This Cell represents the arithmetic total of Cell 4, Cell 11, Cell 18 This Cell represents the arithmetic total of Cell 5, Cell 12, Cell 19 This Cell represents the arithmetic total of Cell 6, Cell 13, Cell 20 This Cell represents the arithmetic total of Cell 59 This cell represents the total number of CMSP individuals with an aid code of 8F who had a re-certification completed in the report month. This Cell represents the arithmetic total of cell 51 + Cell 61 This Cell represents the total number of individuals on hand in the beginning of the month. This number must agree with the number in Cell 77 on last month’s facsimile. This Cell represents the arithmetic total of Cell 65 & Cell 66 This Cell represents the arithmetic total of Cell 52 This Cell represents the total number of individuals that were approved for reasons other than new applications or re-applications (e.g. rescinds). This Cell represents the arithmetic total of Cell 63 & Cell 64 This Cell represents the arithmetic total of Cell 69, Cell 70, Cell 74, Cell 75 & Cell 76 This Cell represents the total number of individuals that were discontinued from CMSP due to end of Certification period. This Cell represents the arithmetic total of Cell 71, Cell 72, Cell 73 This Cell represents the total number of individuals that were discontinued from CMSP due to being found eligible for Medi-Cal (SSI Eligible) This Cell represents the total number of individuals that were discontinued from CMSP due to being found eligible for Medi-Cal (DAPD Eligible) This Cell represents the total number of individuals that were discontinued from 237 final Cell by Cell v1.3 County Medical Services Program Form 237 Cell-by-Cell Description - Final Cell 74 Cell 75 Cell 76 Cell 77 CMSP due to being found eligible for Medi-Cal Other reasons (not stated in cells 71 & 72)) This Cell represents the total number of individuals that were discontinued from CMSP due to client request due to reapplication with budget change This Cell represents the total number of individuals that were discontinued from CMSP due to client request for reasons other than budget change This Cell represents the total number of individuals that were discontinued from CMSP due to reasons not stated in Cell 69, Cell 70, Cell 74 and Cell 75. This Cell represents the arithmetic total of Cell 68 subtracted from Cell 67. 237 final Cell by Cell v1.3 State of California—Health and Human Services Agency Department of Health Services COUNTY MEDICAL SERVICES PROGRAM NOTICE OF ACTION DENIAL/DISCONTINUANCE OF BENEFITS (COUNTY STAMP) Case number: _________________________ District: ______________________________ Denial/discontinuance for: _______________ ____________________________________ (Names) We have reviewed all information available to us about your circumstances, and we find that: U Your application for CMSP dated _________________ has been denied. (Month) (Day) (Year) U Your eligibility to receive CMSP will be discontinued effective the last day of ________________. (Month) The reason for this denial/discontinuance is: Do not throw your plastic ID card away. You can use it again if you become eligible for CMSP or Medi-Cal. The authority that requires this action is in CMSP All County Letter No. 04-07 and/or appropriate CMSP Eligibility Manual sections. If you have any questions about this action, or if there are additional facts relating to your circumstances which you have not reported to us, please write or telephone. We will answer your questions or make an appointment to see you in person. Please remember that this action pertains only to the circumstances you reported to us and that you may reapply at any time. _______________________________________________ _____________________ ___________________ Eligibility Worker Phone Date CMSP 239 A (12/04) APPLICANT COPY CASE COPY State of California—Health and Human Services Agency Department of Health Services PROGRAMA DE SERVICIOS MÉDICOS DEL CONDADO AVISO DE ACCIÓN NEGACIÓN/DESCONTINUACIÓN DE LOS BENEFICIOS (COUNTY STAMP) Número del caso: ______________________ Distrito: ______________________________ Negación/descontinuación para: __________ ____________________________________ (Nombres) Hemos revisado toda la información de que disponemos tocante a su situación y hallamos que: U Su aplicación para CMSP fechada el __________________ ha sido negada. (Día) (Mes) (Año) U Su elegibilidad para recibir CMSP ha sido descontinuada a partir del último día del mes de _____________________. Esta negación/descontinuación se hace porque: No tire su tarjeta de identificación de CMSP. Usted puede utilizarla otra vez si usted es elegible de nuevo para CMSP o Medi-Cal. La autoridad que requiere esta acción esta en la carta “CMSP All County Letter No. 04-07” o en las secciónes apropiadas del Manual de la Elegibilidad de CMSP. Si Ud. tiene alguna pregunta acerca de esta acción o alguna información adicional pertinente a su situación que no nos haya reportado, haga el favor de escribirnos o llamarnos por teléfono. Responderemos a sus preguntas o haremos una cita para verle personalmente. Recuerde que esta acción solamente tiene que ver con la información que Ud. nos reportó y que Ud. puede volver a hacer una aplicación cuando quiera. _______________________________________________ _____________________ ___________________ Trabajador de Elegibilidad Teléfono Fecha CMSP 239 A (SP) (12/04) COPIA DEL SOLICITANTE COPIA DEL CASO State of California—Health and Human Services Agency Department of Health Services COUNTY MEDICAL SERVICES PROGRAM NOTICE OF ACTION APPROVAL/DENIAL OF BENEFITS (County Stamp) Case name: Case number: District: This affects: (Names) Your application for CMSP benefits has been approved. Your CMSP certification period begins the first day of (month/year) ______________ and ends last day of (month/year) ______________. You will be eligible as follows: Month: Gross income: Net nonexempt income: 200% FPL*: _____________ $ ____________ $ ____________ $ ____________ Eligible for the month: Yes Maintenance need: Excess income/monthly share-of-cost: ______________ $_____________ $_____________ $_____________ No $ ____________ $ ____________ Yes _______ through_________ $ _____________ $ _____________ $ _____________ No $_____________ $_____________ Yes No $ _____________ $ _____________ * If this information indicates you are not eligible for a particular month, it was because your Net Nonexempt Income exceeded 200% of the Federal Poverty Level (FPL). For the months that the above indicates you are eligible, you will receive your plastic Benefits Identification Card (BIC) soon. Do not throw this card away. This card is good as long as you are eligible for CMSP. Take this plastic card to your pharmacy, doctor, or other Medi-Cal/CMSP provider when you request health care services. Your BIC will show your provider if you have a share-of-cost to pay. The amount that you pay or obligate to the health care providers will be automatically computed. After your total monthly share-of-cost has been paid or obligated, you will not have to pay for covered health care services received that month from Medi-Cal/CMSP providers. In addition to the plastic BIC as described above, you will soon receive a pharmacy benefits card from MedImpact. You should present this card along with the BIC to your pharmacy when obtaining medications and other pharmacy services. CMSP eligibility is limited to individuals aged 21 through 64 years. CMSP now limits the length of your eligibility. You will automatically be discontinued from CMSP at the end of the month stated above. If you continue to need aid after the date of discontinuance, you can reapply during your last month of eligibility. Please do not reapply sooner. Eligibility Worker Telephone number Date Do not throw your plastic ID card away. You can use it again if you become eligible for CMSP or Medi-Cal. The authority that requires this action is in CMSP All County Letter No. 04-07 and/or appropriate CMSP Eligibility Manual sections. PLEASE READ THE REVERSE SIDE OF THIS NOTICE. CMSP 239 B (12/04) State of California—Health and Human Services Agency Department of Health Services COUNTY MEDICAL SERVICES PROGRAM NOTICE OF ACTION APPROVAL/DENIAL OF BENEFITS RESTRICTED TO EMERGENCY MEDICAL SERVICES (County Stamp) Case name: Case number: District: This affects: (Names) Your application for CMSP benefits has been approved. Your CMSP certification period begins the first day of (month/year) _________________ and ends the last day of (month/year) _________________. You will be eligible as follows: Month: __________________ __________________ Gross income: Net nonexempt income: $ _________________ $ _________________ $ _________________ $ _________________ 200% FPL*: $ _________________ $ _________________ Eligible for the month: Yes No Yes No Maintenance need: $ _________________ $ _________________ Excess income/monthly share-of-cost: $ _________________ $ _________________ * If this information indicates you are not eligible for a particular month, it was because your Net Nonexempt Income exceeded 200% of the Federal Poverty Level (FPL). An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, which in the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patient’s health in serious jeopardy, serious impairment of bodily functions, or serious dysfunction to any bodily organ or part. The emergency must be certified by a physician or other appropriate medical provider (in accordance with Section 51056 of Title 22 of the California Code of Regulations). The Department of Health Services may review the provider’s decision that an emergency service was required. Your application for full CMSP benefits is denied. We have granted you, instead, eligibility for emergency medical treatment. We are taking this action because you are a noncitizen who (one of the following reasons applies): O Does not have satisfactory immigration status according to information received from the Immigration and Naturalization Service (INS). O Lacks documentary proof of satisfactory immigration status for CMSP purposes. O Has been admitted to the United States as a nonimmigrant for a limited period of time. For the months that the above indicates you are eligible, you will receive your plastic Benefits Identification Card (BIC) soon. Do not throw this card away. This card is good as long as you are eligible for CMSP. Take this plastic card to your pharmacy, doctor, or other Medi-Cal/CMSP provider when you request health care services. Your BIC will show your provider if you have a share-of-cost to pay. The amount that you pay or obligate to the health care provider(s) will be automatically computed. After your total monthly share-of-cost has been paid or obligated, you will not have to pay for covered health care services received that month from Medi-Cal/CMSP providers. In addition to the plastic BIC as described above, you will soon receive a pharmacy benefits card from MedImpact. You should present this card along with the BIC to your pharmacy when obtaining medications and other pharmacy services. CMSP now limits the length of your eligibility. You will automatically be discontinued from CMSP at the end of the month stated above. If you continue to need aid after the date of discontinuance, you can reapply during your last month of eligibility. Please do not reapply sooner. Eligibility Worker Telephone number Date Do not throw your plastic ID card away. You can use it again if you become eligible for CMSP or Medi-Cal. The authority that requires this action is in CMSP All County Letter No. 04-07 and/or appropriate CMSP Eligibility Manual sections. PLEASE READ THE REVERSE SIDE OF THIS NOTICE. CMSP 239 P (12/04)
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